Nokea
A 51-year-old client received a kidney transplant. Which of the following signs and symptoms indicates possible rejection of the kidney? Select all that apply.
- A. increased urine output
- B. increase in blood pressure
- C. weight gain
- D. pain in lower back
- E. decreased creatinine
Correct Answer: B,C,D
Rationale: Kidney rejection causes hypertension (B), fluid retention (weight gain, C), and graft pain (D). Decreased urine output (not increased) and elevated creatinine (not decreased) are typical.
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A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:
- A. Douche after intercourse
- B. Void every 3 hours
- C. Obtain a urinalysis monthly
- D. Wipe from back to front after voiding
Correct Answer: B
Rationale: Voiding every 3 hours prevents urine stasis, reducing the risk of bacterial growth and urinary tract infections.
The nurse is caring for a client receiving TPN. The nurse understands that TPN management includes which of the following? Select all that apply.
- A. monitor daily weights and intake and output
- B. monitor serum electrolytes and glucose levels daily
- C. change IV tubing every 48 hours or per facility protocol
- D. change the IV site dressing every 24 hours or per facility protocol
- E. if TPN is unavailable, OK to give D10W or D20W until TPN becomes available
Correct Answer: A, B, C
Rationale: Monitoring weights, intake/output, electrolytes, glucose, and changing tubing per protocol are standard TPN management practices. Dressings are typically changed every 7 days or per protocol, and D10W/D20W are not suitable substitutes for TPN.
The priority nursing intervention for a client with sickle cell crisis is to
- A. administer pain medication.
- B. administer packed RBC.
- C. administer oxygen.
- D. administer IV fluids.
Correct Answer: D
Rationale: IV fluids are the priority in sickle cell crisis to reduce blood viscosity, promote perfusion, and prevent organ damage.
The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client, the nurse should:
- A. Give the client pain medication
- B. Assist the client in dangling her legs
- C. Have the client breathe deeply
- D. Provide the client additional fluids
Correct Answer: B
Rationale: Dangling the legs before walking helps assess for orthostatic hypotension and ensures the client is stable, reducing the risk of fainting.
A child who ingested 18 500-mg acetaminophen tablets 30 minutes ago is seen in the ED. Which of these orders should the nurse do first?
- A. activated charcoal per pharmacy
- B. start an IV with D5W to keep the vein open
- C. gastric lavage PRN
- D. acetylcysteine (Mucomyst) for age per pharmacy
Correct Answer: A
Rationale: Activated charcoal is the priority within 1 hour of acetaminophen overdose to reduce absorption, followed by acetylcysteine to prevent liver damage.